The ACMM was the only person in the occurrence area. He saw little in his peripheral vision and as he turned around, saw his partner already falling onto the moving belt. A number of scenarios were re-enacted with a person of similar build to the HCMM. However, each showed that the combination of the railings and grating consistently prevented anyone from flipping over, or falling between the bars and coming into contact with or near any moving machinery in the area. The non-watertight door leading to the loop belt casing space opens outward and therefore cannot strike a person standing on the landing. The information available suggests that the most likely and reasonable scenario is that the HCMM for reason(s) known only to himself, climbed over the railing and on losing his balance or grip, tripped, fell or slipped onto the moving loop belt. His reason(s) for climbing over the railing remain(s) unknown. There were no obviously apparent mechanical problems nor unusual noises seen or heard by the ACMM as he scanned the machinery. It cannot be ascertained what the HCMM may have seen or heard, which would apparently have caused him to climb over the railing without first shutting down the machinery. The stopping of the discharge machinery either prior to or during discharge is not an unusual occurrence and can occur for a number of reasons, either ship- or shore-related. Again, there was no pressure on shipboard personnel to hasten cargo discharge. The HCMM got along well with his fellow shipmates, no personnel problems were apparent, and this ship was sought out by other mariners within the company; it was known as a 'happy' ship.Analysis The ACMM was the only person in the occurrence area. He saw little in his peripheral vision and as he turned around, saw his partner already falling onto the moving belt. A number of scenarios were re-enacted with a person of similar build to the HCMM. However, each showed that the combination of the railings and grating consistently prevented anyone from flipping over, or falling between the bars and coming into contact with or near any moving machinery in the area. The non-watertight door leading to the loop belt casing space opens outward and therefore cannot strike a person standing on the landing. The information available suggests that the most likely and reasonable scenario is that the HCMM for reason(s) known only to himself, climbed over the railing and on losing his balance or grip, tripped, fell or slipped onto the moving loop belt. His reason(s) for climbing over the railing remain(s) unknown. There were no obviously apparent mechanical problems nor unusual noises seen or heard by the ACMM as he scanned the machinery. It cannot be ascertained what the HCMM may have seen or heard, which would apparently have caused him to climb over the railing without first shutting down the machinery. The stopping of the discharge machinery either prior to or during discharge is not an unusual occurrence and can occur for a number of reasons, either ship- or shore-related. Again, there was no pressure on shipboard personnel to hasten cargo discharge. The HCMM got along well with his fellow shipmates, no personnel problems were apparent, and this ship was sought out by other mariners within the company; it was known as a 'happy' ship. The ACMM did not use the emergency stop for the conveyor belt located nearby as he considered it was just as quick to use his radio. Post-occurrence operational tests of the emergency shutdowns were all satisfactory. The platform railings and grating were such that they would prevent a person working in the area to either slip through or fall over them onto the conveyor belt. There is no obvious reason for the HCMM to have climbed over or gone outside the platform railing. The results of the required drug testing of selected crew members were negative. Emergency medical services and the medical examiner responded quickly to the emergency, however, the physical injuries sustained by the victim were such that nothing could have been done to save his life. The company's safety practices and procedures for the cargo discharge were followed. Both men were experienced in this type of equipment, its operation, safety procedures and cargo discharge operations. There was no pressure on ship personnel to hasten the cargo discharge operations. It is most likely that the HCMM fell or slipped onto the moving belt after having climbed over the guard railings.Findings The ACMM did not use the emergency stop for the conveyor belt located nearby as he considered it was just as quick to use his radio. Post-occurrence operational tests of the emergency shutdowns were all satisfactory. The platform railings and grating were such that they would prevent a person working in the area to either slip through or fall over them onto the conveyor belt. There is no obvious reason for the HCMM to have climbed over or gone outside the platform railing. The results of the required drug testing of selected crew members were negative. Emergency medical services and the medical examiner responded quickly to the emergency, however, the physical injuries sustained by the victim were such that nothing could have been done to save his life. The company's safety practices and procedures for the cargo discharge were followed. Both men were experienced in this type of equipment, its operation, safety procedures and cargo discharge operations. There was no pressure on ship personnel to hasten the cargo discharge operations. It is most likely that the HCMM fell or slipped onto the moving belt after having climbed over the guard railings. It appears most likely that the HCMM lost his life after he climbed over the railing, lost his balance or grip, and tripped, fell or slipped onto the fast-moving conveyor belt machinery.Contributing Factors and Causes It appears most likely that the HCMM lost his life after he climbed over the railing, lost his balance or grip, and tripped, fell or slipped onto the fast-moving conveyor belt machinery.